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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. <br /> Minnesota Stafutes,Chapter1031 or W-series No. <br /> c������� <br /> Township Na•e Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> OCt�lO 117 2� "7 �,. ��. � ��/ <br /> GPS Latdude degrees minutes seconds � <br />,,. LOCATION: �epih Before Sealing �� ft. Original Depth ft. <br /> Longitude degrees minutes seconds p UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Locatlon ingle Aqu'rfer ❑Mutbaqu'rfer <br /> 13ET5 Spruce Place, (lco�o 55364 �� ���ORING Measured ❑Estimated <br /> �� � � �Water Supply Well ❑MonR.Well � <br /> Show exact location ot well or boring Sketch map of well nng <br /> in section grid with"X" location,showing perty ❑Ern.Bore Hole ❑Other �ft. �below ❑above land suAace <br /> N � lines, CASING TYPE(S) <br /> - - - - - -- -- �S[eel ❑Plastic ❑Tile ❑Other <br /> W -�- -i-- -i-- --i-- E � � WELLHEADCOMPLEf10N <br /> Ou[side: ❑Well House inside: ❑Basement Offset <br /> --�- ---- -;-- --i- � <br /> 1�� �Pitless AdapterNnit ❑Well Pit <br /> -`- -�-- -�-- --�-- I <br /> 1 ❑Well Pit ❑Buried <br /> S <br /> �'--�'"+°-� . . ❑Buried <br /> ,.. : .�.a..h'.� :?,K_9`. <br /> PROPERN OWNER'S NAME/COMPANY NA E CASING(S) _ � �� <br /> Diameter � Depth 1 Set in oversize hole? Annular space initially grouted? <br /> Property ner s mailing address it different than well location address indicated above Z �� /� / <br /> in.fromS.` to ��O ft. ❑Yes, �Jo �11YAf ❑No ❑Unknown <br /> �UUV <br /> in.f�om to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. s �� �����'��� <br /> ❑f�' ' ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE/ � ( <br /> Well owner's mailing address if different than property owners adtlress indicated above $CfCCfI ffORl �"� t0 ��ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill �No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO ObStructiOnS removed? ❑YeS ❑ NO DeSCribe <br /> FORMATION <br /> If not knqwn,indicate estimated formation log from nearby well or boring PUMP <br /> • � Type <br /> "� O Removed �Not Present ❑Other <br /> Y <br /> METHOD USED TO SEAL ANNUWR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> RE�i fv�� ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> ,/ ) / � <br /> /[.,,Y"!Y� ,�'-.�`?'";,t%� U ' ' 9 <br /> Grouting Material - rom to ft. yards ba s <br /> C i TY O U f�'�I V � from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING p�ryer unsealed and unused well or boring on property? ❑ Yes �lo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is _ <br /> true to the best of my knowleck�e. <br /> lkm Stod�nl� �Iel I Dril lin�;, Co,. Tnc. 27172 <br /> Contractor Business a�� - ��� License or Registration No. _ <br /> .,-�'" .� ._./ �'' �� <br /> A 'ed ta6x4 i ature / Date <br /> LC3CAL COPV H ������ �.�,3 �b'- r� Q� _,,, �"� ��}._�,,,� <br /> .JL <br /> Name ol Person Sealing Well or Boring ! <br />